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Intensive adherence counseling around the time of HIV treatment initiation significantly reduces poor adherence and virologic treatment failure in sub-Saharan Africa whereas using an alarm device has no effect, according to a study in this week's PLoS Medicine by Michael Chung from the University of Washington, Seattle, USA, and colleagues.

The findings of this study define an adherence counseling protocol that is effective; these findings are relevant to other HIV clinics caring for large numbers of patients in sub-Saharan Africa.

As poor adherence to HIV treatment can lead to drug resistance and inadequate treatment, it is necessary to identify interventions to improve adherence that are inexpensive and proven to be effective in resource-limited settings. The authors randomised 400 patients who were newly diagnosed with HIV and had never before taken antiretroviral therapy to receive adherence counseling alone; alarm device alone; both adherence counseling and alarm device together; and a control group that received neither adherence counseling nor alarm device.

Patients had baseline blood taken to test for HIV-1 RNA and CD4 count and blood was then taken every 6 months for the duration of the study (18 months). After starting HIV treatment, patients returned to the study clinic every month with their pill bottles for the study pharmacist to count and record the number of pills remaining in the bottle.

Patients receiving adherence counseling were 29% less likely to experience poor adherence compared with those who received no counseling. Furthermore, those receiving intensive early adherence counseling were 59% less likely to experience virologic treatment failure. However, there was no significant difference in mortality or significant differences in CD4 counts at 18 months follow-up between those who received counseling and those who did not. There were also no significant differences in adherence, time to virologic treatment failure, mortality, or CD4 counts in patients who received alarm devices compared with those who did not.

The authors conclude: "As antiretroviral treatment clinics expand to meet an increasing demand for HIV care in sub-Saharan Africa, adherence counseling should be implemented to decrease the development of treatment failure and spread of resistant HIV."

Funding: MHC is supported by a K23 grant, US National Institutes of Health (NIH) (5K23AI065222-04). GJ-S received support from an NICHD K24 Award (1K24HD054314-04). This research was funded in part by a 2005 developmental grant from the University of Washington Center for AIDS Research (CFAR), an NIH funded program (P30AI027757) that is supported by the following NIH Institutes and Centers: NIAID, NCI, NIMH, NIDA, NICHD, NHLBI, NCCAM, and NIA. The Coptic Hope Center for Infectious Diseases is supported by the President's Emergency Plan for AIDS Relief (PEPFAR) through a cooperative agreement (U62/CCU024512-04) from the US Centers for Disease Control and Prevention (CDC). The ALRT PC200 pocket digital alarms used in this study were donated by ALR Technologies, Atlanta, Georgia, US. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing Interests: Academic Editor Edward Mills has collaborated with and published one previous paper with Michael Chung, the lead author on this paper.

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